Effects of Pediatric Asthma Education on Hospitalizations and Emergency Department Visits: A Meta-Analysis June 3, 2007 Janet M. Coffman, PhD, Michael D. Cabana, MD, MPH, Helen A. Halpin, PhD, Edward H. Yelin, PhD University of California, San Francisco University of California, Berkeley Institute for Health Policy Studies

2 Background and Rationale  NHLBI guidelines recommend asthma education for all patients  Latest meta-analysis only assessed studies published prior to 1999  A number of additional studies have been published over the past eight years  Innovations in treatment of asthma  Dissemination of NHLBI guidelines

3 Research Question  Compared to usual care, does the provision of asthma education to children and their parents reduce  Asthma ED visits?  Asthma hospitalizations?

4 Methods  Research Design: Meta-analysis  Databases:  Cochrane Database of Systematic Reviews  Cochrane Register of Controlled Trials  PubMed  Cumulative Index of Nursing and Allied Health Literature (CINAHL)

5 Methods  Inclusion Criteria  Enrolled children aged 2-17 years with a clinical diagnosis of asthma  Conducted in the United States  Compared asthma education to usual care  Included a control or comparison group  Examined ED visits and/or hospitalizations for asthma

6 Methods  Calculated pooled findings for  Odds of an event  ED visit  Hospitalization  Mean Number of events  ED visits  Hospitalizations

7 Methods  Analysis  Estimated fixed effects models for all outcomes  Conducted Chi-Square test to determine whether results of the studies pooled are heterogeneous  Where results were heterogeneous (i.e., p<0.1 for Chi-Square test), estimated random effects models  Small number of studies precluded performing meta-regression to explore sources of heterogeneity

8 Results of Literature Search  174 abstracts reviewed  23 articles met the inclusion criteria  Research design  19 studies (83%) were RCTs or cluster RCTs  4 (17%) were nonrandomized studies

9 Study Characteristics  Demographics: in 16 studies (70%) most of the children enrolled were low-income  Target of intervention: 57% provided education to both children and parents  Types of education: included individual counseling, group classes, telephone calls, and educational computer games  Types of settings: included outpatient clinics/ physician offices, emergency departments, schools, and homes

10 Odds of ED Visit Education vs. Usual Care – Fixed Effects Test of OR = 1: z = 2.61, p = 0.009; Test of Heterogeneity: χ2 =14.59 (df = 10), p = 0.148

11 Odds of Hospitalization Education vs. Usual Care – Random Effects Test of OR = 1: z = 0.70, p = 0.482; Test of Heterogeneity: χ2 =13.31 (df = 7), p = 0.065

12 Mean ED Visits Education vs. Usual Care – Random Effects Test of SMD = 0: z = 2.40, p = 0.016; Test of Heterogeneity: χ2 =24.48 (df = 13), p = 0.027

13 Mean Hospitalizations Education vs. Usual Care – Random Effects Test of SMD = 0: z = 2.53, p = 0.012; Test of Heterogeneity: χ2 =7.68 (df = 4), p = 0.104

14 Possible Reasons for Heterogeneity  Although there are not enough studies for meta-regression, findings for effects on ED visits appear to differ based on  Type of education: individual education more effective than group education  Setting: providing education in clinical settings more effective than providing in school

15 Limitations  Only assessed effects on ED visits and hospitalizations  Lack of consistent measures of severity of asthma symptoms  Potential publication bias  Results may not generalize to  Upper- and middle-income children  Children outside the USA

16 Conclusions and Implications  Pediatric asthma education reduces  Odds of an ED visit  Mean ED visits  Mean hospitalizations  However, in our sample, pediatric asthma education does not affect odds of hospitalization  Health plans should provide incentives for pediatric asthma education

17 Thank You  Co-authors  Michael D. Cabana, MD, MPH, UCSF  Edward H. Yelin, PhD, UCSF  Helen A. Halpin, PhD, UC-Berkeley  Funders  California Health Benefits Review Program  National Institutes of Health (#HL70771)

18 QUESTIONS?

19 Opportunities for Research  Cost-effectiveness of pediatric asthma education  Identification of the most important components of asthma education  Which children benefit most from asthma education

20 Why Limit Meta-Analysis to US Studies? Interested in effect of pediatric asthma education on ED visits ED utilization depends in part on a country’s health care system In the US, many low-income children have poor access to primary care Including studies from countries with universal health care may have confounded the results

21 Comparisons of Different Educational Interventions  Comparisons of different educational interventions suggest that greater reductions in hospitalizations and ED visits were associated with More sessions More comprehensive education More interactive modes of education